Sunday, December 23, 2012

'Drop the language of disorder' - a recent paper

Drop the language of disorder

Evidence-Based Mental
Health Online First, published on September 21, 2012 as 10.1136/eb-2012-100987

Peter Kinderman,1 John Read,2 Joanna
Moncrieff,3 Richard P Bentall1

1Institute of Psychology, Health and Society, University of
Liverpool, Liverpool, UK 2Psychology Department, University of Auckland,
Auckland, New Zealand 3Mental Health Sciences Unit, University College London,
London, UK

We may be on the cusp of a major paradigm shift in our
thinking about psychiatric disorders. The proposed revision of the American
Psychiatric Association's Diagnostic and Statistical Manual (DSM) of Mental
Disorders franchise for the classification and diagnosis of human distress,
which will lead to the 5th edition (DSM-V), has served as a catalyst for a wide
range of criticism (most notably at www.ipetitions.com/petition/dsm5/). This
has identified serious inadequacies in the specific proposed revisions, and has
also highlighted scientific, philosophical, practical and humanitarian
weaknesses in the diagnostic approach to psychological well-being, underpinning
the DSM. This debate provides the opportunity to propose a more scientific
grounded and clinically useful system.

PROBLEMS WITH DIAGNOSIS

Diagnostic systems in psychiatry have always been criticised
for their poor reliability, validity, utility, epistemology and humanity. With
great effort, and standardised approaches, it is possible for reliable
diagnoses to be generated. But such practices are rarely adopted in clinical
settings, and as we know, it is entirely possible to reliably diagnose invalid
diagnoses (the mere agreement between diagnosticians is no guarantee that
diagnoses correspond to meaningful clusters of symptoms, with distinct
pathophysiology and aetiology, which predict the effectiveness of particular
treatments).

The poor validity of psychiatric diagnoses—their inability
to map onto any entity discernable in the real world—is demonstrated by their
failure to predict course or indicate which treatment options are beneficial,
and by the fact that they do not map neatly onto biological findings, which are
often nonspecific and cross diagnostic boundaries. For example, depression and
anxiety disorders are so comorbid that it is often arbitrary which diagnosis is
given to a patient; schizophrenia symptoms are usually accompanied by mood symptoms
and overlap with those of bipolar disorder, and it is unclear as to whether
bipolar disorder is distinct from major depression.

In epistemological terms, diagnoses convey the idea that
people’s difficulties can be understood in the same way as bodily diseases,
which excludes the possibility of finding meaning in people’s ‘disordered’
responses and experiences, and thus prevents people from understanding how they
might use their own resources to address their difficulties. Worse still,
diagnoses are used as pseudo-explanations for troubling behaviours (he did this
because he has schizophrenia) without consideration of the circularity of that
argument, and the broader context (eg, whether a paranoid person has actually
been victimised). And as a result of all these failings, the diagnostic tools
that we are currently living with mean a person’s social and interpersonal
difficulties are often ignored in the hope that the right medication regimen
will achieve the desired return to normal functioning.

If implemented, the DSM-V would lead to a lowering of a
swathe of diagnostic thresholds. This would inflate the assumed prevalence of
mental health problems in the general population. This might be good news for
pharmaceutical companies, but is a potential threat to the general public and
especially vulnerable populations such as children and older people. The
clients and the general public are negatively affected by the continued and
continuous medicalisation of their understandable responses to their experiences;
responses that undoubtedly have distressing consequences which demand helping
responses, but which are better understood as normal individual variation than
as illnesses.

DSM-V would, if implemented, see an increased emphasis on
the supposed biological underpinnings of psychological distress, in that the
language of biological illness will be reinforced. This is again concerning,
since most scientific evidence points to the fact that complex, individual,
interactions between biological, social and psychological factors lead to these
distressing experiences.

Finally, such approaches, by introducing the language of
‘disorder’, undermine a humane response by implying that these experiences
indicate an underlying defect. We have seen significant opposition to the
proposal that grief, in essence, be pathologised (1) but the pathologising of
normality in DSM-V is more pervasive, and is shared in all medical diagnostic
systems. The death of a loved one can lead to a profound, and long-lasting,
grieving process. War is hell. In what sense is it a ‘disorder’ if we remain
distressed by bereavement after 3 months or if we are traumatised by the
experience of industrialised military conflict? It is important for all of us
to ensure that our children learn appropriately to regulate their emotions and
grow up with a sense of moral and social responsibility. But is it appropriate
to invoke the concept of ‘disorder’ when children need extra help?

AN ALTERNATIVE

We need a wholesale revision of the way we think about psychological
distress. We should start by acknowledging that such distress is a normal, not
abnormal, part of human life—that humans respond to difficult circumstances by
becoming distressed. Any system for identifying, describing and responding to
distress should use language and processes that reflect this position. We
should then recognise the overwhelming evidence that psychiatric symptoms lie
on continua with less unusual and distressing mental states. There is no easy
‘cut-off’ between ‘normal’ experience and ‘disorder’. We should also recognise
that psychosocial factors such as poverty, unemployment and trauma are the most
strongly evidenced causal factors for psychological distress (2) although, of
course, we must also acknowledge that other factors—for example, genetic and
developmental—may influence the magnitude of the individual’s reaction to these
kinds of circumstances.

There are alternative systems for identifying and describing
psychological distress that may be helpful for the purposes of clinical
practice, communication, record-keeping, planning and research, such as the
operational definition of specific experiences or phenomena. Some international
effort will be needed to develop a shared lexicon, but it is relatively
straightforward to generate a simple list of problems that can be reliably and
validly defined; for example, depressed mood, auditory hallucinations and
intrusive thoughts. There is no reason to assume that these phenomena cluster
into discrete categories or other simple taxonomic structure. Indeed, the
extent to which the phenomena co-occur may be a function of development and
social circumstances. As with many other areas of medicine (particularly
primary care) and wider civil society, such problems lend themselves to communication
between professionals and the planning of services, especially if it is
recognised that the operational definition should include some measure of
severity.

While some people find a name or a diagnostic label helpful,
our contention is that this helpfulness results from a knowledge that their
problems are recognised (in both senses of the word), understood, validated,
explained (and explicable) and have some relief. Clients often, unfortunately,
find that diagnosis offers only a spurious promise of such benefits. Since, for
example, two people with a diagnosis of ‘schizophrenia’ or ‘personality
disorder’ may possess no two symptoms in common, it is difficult to see what
communicative benefit is served by using these diagnoses. Surely a description of
a person’s real problems would suffice? A description of an individual’s actual
problems would provide more information and be of greater communicative value
than a diagnostic label.

For clinicians, working in multidisciplinary teams, the most
useful approach would be to develop individual formulations; consisting of a
summary of an individual’s problems and circumstances, hypothesis about their
origins and possible therapeutic solutions. This ‘problem definition,
formulation’ approach rather than a ‘diagnosis, treatment’ approach would yield
all the benefits of the current approach without its many inadequacies and
dangers. It would require all clinicians— doctors, nurses and other
professionals—to adopt new ways of thinking. It would also require the rewriting
of most standard textbooks in psychopathology (which typically use DSM
diagnoses as chapter headings).

For researchers, trying to understand the causes of, and
proper responses to, such distress is actively hampered by the diagnostic
systems currently used.

Whether we are pursuing biological, psychological or social
causes of human distress, an invalid diagnostic system is an active
hindrance—if there is no validity to a label such as ‘schizophrenia’, how can
researchers finds its cause? Researchers would be better advised to study the
nature of, causes of and proper response to specific, identified problems.
Indeed, this process has already begun, with a rich literature on social
origins, biological substrate and consequences of particular psychiatric
phenomena (eg, hallucinations, paranoid delusions and thought disorder)
emerging over the last 20 years.

Clinicians are also likely to be more effective if they
respond to an individual’s particular difficulties rather than their diagnostic
label.